Abstract

Practice-based commissioning (PBC) in the UK is intended to improve both the vertical and horizontal integration of health care, in order to avoid escalating costs and enhance population health. Vertical integration involves patient pathways to treat named medical conditions that transcend organisational boundaries and connect communitybased generalists with largely hospital-sited specialists, whereas horizontal integration involves peerbased and cross-sectoral collaboration to improve overall health. Effective mechanisms are now needed to permit ongoing dialogue between the vertical and horizontal dimensions to ensure that medical and nonmedical care are both used to their best advantage. This paper proposes three different models for combining vertical and horizontal integration – each is a hybrid of internationally recognised ideal types of primary care organisation. Leaders of PBC should consider a range of models and apply them in ways that are relevant to the local context. General practitioners, policy makers and others whose job it is to facilitate horizontal and vertical integration must learn to lead such combined approaches to integration if the UK is to avoid the mistakes of the USA in over-medicalising health issues.

Keywords

Introduction

Practice-based commissioning (PBC) in the UK
National Health Service (NHS) is an attempt to plan
the best possible health care for entire populations (see Box 1).1 PBC will provide a local planning facility,
led by general practitioners (GPs), to complement the
systems-wide perspective of primary care trusts (PCTs).
Together they will administer NHS funds for the
population served.2

In order to plan best care, PBC must enable comprehensive
integration of healthcare effort. Vertical
integration involves patient pathways to treat named
medical conditions, connecting generalists and specialists,
whereas horizontal integration involves broadbased
collaboration to improve overall health.3 Comprehensive
integration includes a good balance of both.

Box 2 summarises the features of these two different
types of integration. Broadly speaking, in terms of its
data sources and status, vertical integration is the
domain of medicine – diseases are researched as discrete
entities; linear care pathways consider one disease at a
time; discrete treatment packages are costed and evaluated
for their anticipated effects; quality assurance
emphasises achievement of quantifiable outcome targets.
Broadly speaking, horizontal integration is the
domain of social sciences – multidisciplinary teams
and interagency collaboratives learn, inquire and innovate
together; cross-organisational planning leads to a
synchrony of effort that creates environments for health;
quality assurance emphasisesmechanisms whereby broad
groups of stakeholders can examine whole systems of
care for their diffuse and unexpected long-term effects
and then act for co-ordinated quality improvements.

Box 2: Features of vertical, horizontal and comprehensive integration

Specialist treatment for cancer requires vertical integration
to ensure that best treatments are given, whereas
end-of-life care requires horizontal integration to
ensure co-ordinated support from all involved. Treatment
of severe mental illness requires vertical integration
for generalist and specialist medical practitioners
to work together in the best way, whereas horizontal
integration is needed to create environments that will
develop confident creative citizens. Commissioning
must prioritise both dimensions.

GPs are naturally placed to work in the horizontal
plane since they have a traditional orientation towards
families and communities aswell as individuals. However,
targets such as those contained in the NHS Quality
Outcomes Framework since 2003, ceaseless structural
changes, and the increasingly part-time nature of general
practice are making it difficult to sustain this orientation.
Furthermore, GPs have been trained in medical
science and are concerned with the micro-economics
of small enterprises – both of these appeal for their
explanatory frameworks to simple and direct assumptions
about how a ‘cause’ has an effect (known as the
science of positivism).4 GPs consequently have little
exposure to social science evidence that broader change
is not straightforward:5 future developments cannot
be predicted in the simple way that their training will
lead them to assume. Instead multiple factors constantly
interact and adapt to each other to shape a general trend,
as assumed by the science known as constructivism.4
Hidden interconnected factors dominate people’s behaviour,
more powerful than the simple explanations
people use, as assumed by the science known as critical
theory.4 Without a good grounding in these profound
and non-linear sciences, PBC is more likely to produce
integrated medical systems, rather than integrated health
systems.

Combined vertical and horizontal
integration: a holy grail

The need to integrate health systems (called ‘comprehensive
primary health care’) was agreed at the World
Health Organization (WHO) Alma Ata conference of
1978. To achieve this level of integration, healthcare
policy must be underpinned by the three principles of
participation, equity and intersectoral collaboration.6
However, political and practical obstacles meant that
this did not happen.7

In this year of the 30th anniversary of Alma Ata,
comprehensive primary health care is again being
seriously considered, with a major new WHO declaration
scheduled. Consequently healthcare reforms in Europe now commonly emphasise community participation,
interprofessional learning and collaboration
across the public and independent sectors.8 The national
clinical director (England) believes thatPBCcould be a
good vehicle to achieve comprehensive primary health
care.9 This paper describes models that could help
PBC to achieve this.

Meads’ research into ideal types
of primary care organisation

Many models of primary care organisation have arisen
out of the inspiration of Alma Ata. In the UK, community
oriented primary care,10 and ‘Healthy Cities’
are two well-known examples.11 But there has been little
research into ideal types of primary care organisation
that might help to realise an Alma Ata vision. The
concept of ‘ideal type’ is associated with the sociologist
Max Weber. It is useful because it stresses those
elements that are common to a particular type, providing
a ‘unified analytical construct’.12 Toan extent, the
various effects of a particular type can be predicted,
including their effects on integration. In reality, every
organisation is a hybrid of different types, but within
these hybrids, ideal types can be discerned. Commissioners
can choose to strengthen one or another type
to change the overall effect of their existing strategy for
integration.

To help make sense of primary care organisation in
the 21st century, Meads visited and studied primary
care developments in 31 countries that were undergoing
major healthcare reforms.13 This led him to
examine in detail 24 case studies that illustrated the
broader principles of different types. This extensive
study presents the most authoritative contemporary
examination of different types of organisation of
primary care. We summarise Meads’ case studies in Box 3. Meads identified six ideal types of primary care
organisation. Below, we synthesise and analyse these
ideal types to propose three different models of comprehensive
integration. These are not mutually exclusive,
and PCTs and PBC may use components of
different models in ways that are locally relevant. In
order to avoid bias, two authors (PT and KS) analysed
Meads’ work in advance of inviting him to join us as a
co-author. Meads agreed with our analysis of his work,
enhancing the validity of our interpretations.

At three different stages of NHS evolution, Meads’ six
ideal types naturally group into three pairs, each of
which provides a model of combined horizontal and
vertical integration. We examine these three models,
highlighting options for PBC.

Outreach franchise was the status of general practice
immediately after the invention of the NHS in 1948.
GPs were independent contractors paid a fee for every
patient on their list – but what they did was largely left
up to them. The polyclinic bears comparison with the
community hospital that was also a feature of the NHS at that time – here specialists rubbed shoulders with
GPs, and their patients lay side by side in adjacent
beds. Together these provided a model of vertical
integration – from general medical practice to specialist
medical practice.

Our NHS Our Future signals a re-visitation of the
polyclinic idea to enhance vertical integration, as a form
of intermediate care where specialists and generalists
can meet.14 Professor Lord Darzi, its author, stresses
that he uses the term ‘polyclinic’ to mean more than
vertical, medical integration. He said in an interview
with one of this paper’s authors (PT):15

‘I strongly believe we must get together people from these
different health care settings, which are historically built
around primary, secondary, and tertiary ... and colleagues
doesn’t mean just medical colleagues, it means nursing
colleagues ...

... Let me put on record. Polyclinics are not buildings.
Polyclinics are my way of describing integrated service
provision ...

I think we all need to need to reach that maturity (of
leading ‘‘bottom up’’ developments). Not just the Department
of Health. Actually all the national organisations
need to think about bottom-up.’

The polyclinic model could be adapted to act as a
focus for horizontal integration. A polyclinic, whether
a large building or an integrated federation of primary
care organisations, could house teams of community
workers who plan a breadth of community activities,
including multicultural events, projects that develop
social capital, self-help activities and international exchange.
Cross-over planning between the vertical and
horizontal functions could lead to one-stop shops that
help local people to navigate whole systems of care.
Networks for research and clinical excellence could be
connected at a ‘polyclinic’, providing a way for universities
to channel their local involvement. Recruitment
into clinical trials could be led by this unit that
would negotiate a fee for this service to fund locally
led innovations and audit, in a similar fashion to the
approach adopted by Finland’s primary care centres.16

Medical influence will be strong in this first model,
and this will inevitably emphasise a medical view of
health and disease. That may not be enough to realise
the broader aspirations of Alma Ata – that health is
everyone’s concern.

Extended general practice and district health systems
resemble UK arrangements after the 1990 healthcare
reforms when the focus of service delivery changed
from the individual GP to the multidisciplinary
general practice organisation. Nurses and allied health
professionals became employed by NHS ‘community
trusts’ that also managed hospitals. They attached
their staff to general practices to form extended teams,
and developed shared vision and mission through
residential team-building workshops.17 An interorganisational
local organising team facilitated these
workshops and solved political problems.18 This led
to enhanced ability to integrate in the horizontal
dimension, providing an infrastructure of facilitation
and communication to support interdisciplinary
innovation.

Multiple variations to the basic model were made
in those years, to enable creative interaction between
activities in the vertical and horizontal planes.19 In
Liverpool, local multidisciplinary facilitation teams
helped primary care teams to use action learning and
participatory action research to improve quality within
geographic areas;20 working with the Healthy City
2000 project they brokered cross-city collaborations
for multiple projects that involved general practice
teams, specialists, city council, voluntary groups, schools,
youth and community groups, trade unions and the
media.21 In Sheffield, facilitators used data from GP
computers to support local reflection and action for
change. In South London a network of multidisciplinary
general practices provided local leadership for research,
audit, quality improvements and student placements.
The Kings Fund (London) led whole-system interventions
throughout the UK that enabled synchronised
cross-organisational policy between health and social
care and the voluntary sector.22

PBC could revitalise these models and from them
develop a powerhouse of multidisciplinary learning,
innovation and community development at local level.
This could provide a focus for ‘bottom-up’ leadership
of inquiry and action, to complement the more ‘topdown’
approach that will naturally flow from Model 1.

Model 3: Managed care and
community development agencies –
integrating through networks

Managed care and community development agencies
are models that change the focus of service delivery
from individuals and discrete multidisciplinary primary
care teams to whole systems of care. Both claim
to be models of comprehensive (whole-system) integration.
But they conceptualise the task differently.

The signal difference between managed care and
community development agencies is revealed in this
quotation from a leader of a Peruvian agency: ‘We see
health as a ‘‘citizen’’ not a ‘‘profession’’ issue’ (p.100).13
Managed care uses the term ‘horizontal integration’ to
mean treatment in the community of named (medical)
conditions.23 A community development agency locates the same term within its framework for
participatory democracy, which embraces all things to
do with being a healthy society, of which treating
diseases is merely a part.

Managed care therefore virtually ignores horizontal
integration as we have defined it. Instead it is a
sophisticated version of vertical, targeted integration
– targeted at a comprehensive range of diseases.

Managed care and community development agencies
have quite different strengths and weaknesses. Managed
care uses sophisticated ways to track patient
movements and costs, but has limited ability to facilitate
local learning and co-ordinated action for health.
By contrast, community development agencies are
effective at enabling local learning and co-ordinated
action, but are comparatively slow at producing ‘topdown’
direction, as this quotation reveals:

‘... while lay representations and contributions can be
significantly enhanced, so too can the power afforded
minorities, vested interests, corrupt cartels and even
unrepresentative community factions.’13

However, its ability to fashion a broad consensus and
to motivate those involved to ‘give back’ are major
strengths. Meads states:

‘it can go a long way towards ensuring that healthcare
expenditure and priorities become less of a political
burden for hard-pressed governments.’13

Both use networks and systems to connect a diversity
of stakeholders. Managed care emphasises the role of
these in checking that agreements are understood and
adhered to. Community development agencies emphasise
their use as a mechanism for co-ordinated
collaborative development.

Many advocate the managed care model for the
UK.24 Systems to support it have already been developed.
The Quality and Outcomes Framework, DrFoster,
Choose and Book, Payment by Results – these are
data-management systems that help to track patient
movements and costs.However, there is little evidence
within PBC plans of horizontal integration as it would
be defined by community development agencies. If
this is not added, as Mexico for example has discovered,
undue medicalisation appears inevitable, with all its
associated dangers, including excess professional specialisation
and regulatory capture, accelerating costs,
and reduced population health.25,26

A model that integrates vertical and horizontal
activities might include features of both managed
care and community development agencies. Meaningful
interaction between those who see health as a
citizen issue and those who see it as a professional issue
is likely to resemble ongoing dialogue, more than
hard-wired connection.27 Participatory and wholesystems
approaches to research will be needed.28

Discussion

Both Meads’ original work and our further analysis of
it, give commissioners a range of options to plan for
comprehensive integration.

PBC aims for combined vertical and horizontal
integration, but dominant ways of thinking about
how to achieve these, coupled with inadequate training
of NHS leaders (not only GPs), are likely to
emphasise the vertical dimension. In consequence,
PBC is in danger of achieving the opposite of its
purpose, replicating the mistakes of North America
and the WHO,3 by paying too much attention to the
medical aspects of health problems, and insufficient
attention to the processes of social cohesion.

Leaders must constantly assert a need for a meaningful
balance between the vertical and horizontal
dimensions, in pursuit of comprehensive primary
health care as envisaged at Alma Ata.3 Further, they
must pilot mechanisms that enable vertical and horizontal
activities to helpfully mould each other through
ongoing whole-system inquiries and action. This will
allow the parts (care of specific diseases) and the whole
(the health of individuals, communities and healthcare
systems) to remain in tune with each other.29 The
three models described above provide options to
achieve this.

An important take-home lesson fromthis analysis is
that combined horizontal and vertical integration can
happen in a natural, evolutionary way when those
involved have time to think the issues through, and
when appropriate theories of change are used. Health
service policy must be careful to enable this, and avoid
heavy-handed micromanagement that prevents people
thinking and acting for themselves. They must remember
that the best configuration depends on the
local political, cultural and historical context, and enable
creative thinking at all levels. Lord Darzi, facilitator of
the present NHS reforms, has given a clear commitment
to this bottom-up approach. Whether this can
be practically realised will depend on the courage and
actions of all involved, and not merely his personal
determination.

Much is changing in a way that could make very
positive improvements in participation, equity and
intersectoral collaboration. Already the theory and
practice of whole-system learning and change is being
introduced into thecommissioning process. The practical
work of developing local alliances for polyclinics
offers multiple opportunities for multidisciplinary
leadership teams to learn how to facilitate broad
participation in service developments. It would be
fitting, in the year that holds the 30th anniversary of
Alma Ata and the 60th anniversary of the NHS, that
the UK NHS points the way towards much-needed models of comprehensive integration for health and
care.

Funding

Support was received from a professor (KS) in receipt
of a grant from the American Cancer Society.